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,iy�Rrar` <br />Safety and Buildings Division <br />Co11-1v.ef-11 <br />Sanitary Permit Number (to be filled in by Co.) <br />1400 E Washington Ave <br />P_O. Box 7162 <br />Madison, WI 53707-7162 <br />`1 <br />osFssto,����� <br />Sanitary Permit Application <br />StateTransaction Number <br />AIn <br />accordance with SPS 38321(2), Wis_ Adm. Code, submission of this form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit_ Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.0 1 m), Stats. <br />��� � <br />Parcel # O _ O.Z <br />I. Application Information - Please Print All Information <br />Prop rty Owner's Name <br />� <br />/ K2. <br />O S— dol. o/DODO <br />Property Owner's Mailing Addmss <br />Property Location P C <br />Ord P114 C e <br />Govt. Lot_ <br />'/4 '/4, Section <br />'/4, <br />City, State <br />Zip Code <br />Phone Number <br />Pyr a r� LA-Ke <br />5'37.2 <br />q <br />ter/ v� / �� <br />(circle one)_ <br />T _� N; R / T E ori <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />�1 or 2 Family Dwelling -Number of Bedrooms <br />/ <br />l� <br />Block # <br />D City Of <br />D Public/Commercial - Describe Use <br />i <br />^- <br />11 State Owned -Describe Use <br />D Village of <br />'Town of SG o7;;- <br />CSM Number <br />©3 <br />� / <br />111. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A_ <br />D New System <br />D Replacement System <br />Treatment/Holding Tank Replacement Only <br />D Other Modification to Existing System (explain) <br />B• <br />❑Permit Renewal <br />El Permit Revision <br />Change of <br />❑ Chan <br />❑Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />I -Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound > 24 in. of suitable soil D Mound < 24 in. of suitable soil <br />D Holding Tank D Other Dispersal Component (explain) D Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Di: -ersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />,fo v <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units 2 <br />fl m <br />New Tanks Existing Tanks o "2 � =9 <br />Septic or aldmg-Tnnk <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />227691 <br />Business Phone Number <br />715-349-7286 <br />WADE RUFSHOLM <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VIII. Coun /De artment Use Only <br />Approved <br />0 Disapproved <br />Permit Fee 0 <br />$'3 <br />Date Issued <br />Issuing Agent Si <br />11 Owner Given Reason for Denial <br />�" O <br />s = J D —(Y <br />for DisapprovalPPROV[D / / <br />IX. Conditions of Approval/R7p;�Ilee^vl <br />� � <br />��7`,�tG <br />o � <br />Attach to complete plans Ior me system anu summa m me wuory oo.y uu pap- out .c ...an ........---- <br />